VBJ Article - November 2017

  Back

08/11/2017

Planes, Trains and Automobiles – a simplified journey through complementary veterinary medicine

Article republished from VBJ magazine November 2017

Written By: Dr. Stephen Barabas BSc., BVMS., MRCVS, VBS DIrect Ltd

We are living through an incredible period of growth, discovery and enhanced knowledge of medical science and disease. The choices for veterinarians and nurses in drugs and vaccines, new diseases and disorders, diagnostics and treatment options are truly awe inspiring. In parallel there is a change in people’s behaviour and desire to have “natural” therapies for their own health and their pets’. This has driven vets and nurses to seek alternative complementary medicines, supplements and treatment therapies for their customers.

Like Steve Martin’s trip on “Planes, trains and automobiles” there are many options available to get to the final destination, but in the field of complementary medicine some of these therapies might lead to dead ends or even might be detrimental to the animal’s health. This article aims to set the reader on a good course to help identify the correct multi-modal complementary therapies for their practice and customers.

Regardless of your choice of complementary products or equipment, three key factors are always essential: clinical proof on the actual product, ease of implementation and use, and return on investment. Investing time and understanding the options is critical in making good choices for your own business. Lack of regulation, unlike prescription medicines, makes this field of laser technology, regenerative medicine, and other complementary medicines a minefield without due diligence.

WHAT IS LASER LIGHT THERAPY?

The body reacts to light energy: when exposed to sunlight our skin tans via stimulated melanocytes, vitamin D is boosted, larger quantities of serotonin are released in the brain. These reactions are mediated by cellular molecules that react to specific light photons.

Over 50 years of research have unraveled which wavelengths of light trigger positive reactions in our tissues, with recent improvements in photobiostimulation created by the arrival of Class IV laser power and tissue specific pulse frequencies. Recent bio-medical research and enhanced laser technology have optimised the positive effects of light stimulation over a large range of applications from accelerated wound healing to post-surgical rehabilitation and dentistry, and reducing acute and chronic pain, inflammation and swelling.

Laser therapy uses selected wavelengths of light to stimulate key molecules in tissues. This activates a cascade of photochemical reactions that boosts cellular metabolism, also improving circulation, oxygenation and absorption of nutrients. This creates an optimal healing environment for tissues to recover. As the injured area returns to normal, function is restored and pain is relieved.

Laser therapy has proven successful on a vast range of applications - from acute injuries to chronic pain, from musculoskeletal conditions to wounds. It is a safe, non-invasive, drug-free technique that promotes the body’s own reparative processes. It is these aspects that have made Class IV laser therapy so beneficial clinically and economically in general first opinion and referral equine or small animal hospitals.

NOT ALL THERAPEUTIC LASERS ARE CREATED EQUALLY

Models and brands can differ significantly. Some lower energy devices can have limited therapeutic action and produce mixed outcomes. Devices categorized as ‘Class IIIb’ emit lower amounts of energy, requiring long laser sessions to produce the required therapeutic dosage.

The new generation of lasers, called ‘Class IV’, are more powerful and can deliver a therapeutic dosage to deep tissues in few minutes. The most advanced therapeutic Class IV laser, feature multiple different wavelengths and have large variation in pulse frequencies resulting in a success rate of 90% in chronic musculoskeletal cases (NHS data).

ARE THERE SIDE EFFECTS?

The therapy does not normally induce any side effects because it does not introduce anything foreign into the body. Light is energy, and laser therapy ‘simply’ provides carefully calibrated energy to tissues to boost their natural reparative processes.

The treatment is pain free to the vast majority of patients. When treated with a Class IV laser you will generally perceive a warm sensation that patients describe as soothing and relaxing - whilst treatments with the weaker Class IIIb lasers can’t be perceived.

IMPLEMENTATION of LASER THERAPY

It is important due diligence is shown in choosing a laser suitable for the practice and its client base. Key considerations are: who is going to perform the laser therapy? Are short treatment times important? What disorders will you want to use the laser on? Have you got good clinical papers to support the specific laser’s efficacy? What marketing support and training are provided?

Chiltern Referrals, “K-Laser has strengthened our relationship with our owners as their pets are being seen regularly at the clinic and this facilitates early detection of any deterioration in their condition or osteoarthritic flair up………it is also an essential part of post-surgical rehabilitation used by our in-house physiotherapist.”

Donna Carver at GUVS states, “we use the laser on every post-surgical and osteoarthritic patient we see through the Glasgow University physiotherapy and hydrotherapy service…..now I am finding the additional K-Laser therapy allows us to regain almost 100% range of motion in dysplasic hips, where previously we achieved 60%”.

"At Pennard Vets we have been using a Cube 4 Laser for many years now, at two of our branches, and we couldn't imagine not having access to it now! We use multi-modal pain relief for most of our clinical cases, including chronic cases like osteo-arthritis and acute cases like sprains and strains, and as part of our canine rehabilitation service, often in combination with hydrotherapy. It has proven to be a reliable, cost effective, pain free and side-effect free method of administering pain relief to a patient, which is much appreciated by the patient, its owner, and us!

We also use the K-Laser for standard post-operative wound treatment in cases of routine surgery such as spays and castrations, as well as many other surgical cases. The evidence is clear when these cases are seen back a few days after the surgery”, Pete van Dongen, Clinical Director.

HYDRO THERAPY HOW DOES IT HELP PAINFUL PATIENTS AND REHABILITATION

The hydrotherapy pool allows the animal to exercise in a non-weight bearing environment which relieves pressure on joints, reducing pain and encouraging movement. In the aquatic treadmill, the water height can be adjusted to precisely control the amount of weight bearing as the animal strengthens or recovers.

It is difficult to move quickly within water so the water has a cushioning or protective quality reducing the risk of injury. This same quality means that the dog has to work hard to move forward when swimming and in turn this helps to increase muscle strength and bulk. Within water animals are also subject to hydrostatic pressure and this can help to reduce swelling and pain especially in the lower limbs.

In conjunction with veterinary treatment Hydrotherapy can improve the quality and rate of healing following surgery and traumatic injury, or chronic joint pain. It can also help with the treatment of medical conditions:

  • Reduced pain, swelling and an anti-inflammatory effect because of hydrostatic pressure which leads to an increased range of movement in water.
  • Non-weight bearing environment that can help reduce pain and swelling following surgery or injury. It enables the dog to move freely in the water increasing the circulation and reducing stiffness.
  • Warm water increases the circulation of the blood to the muscles increasing the supply of oxygen and nutrients and flushing away waste products. This leads to muscle relaxation and a reduction in pain and stiffness. Improved circulation reduces swelling around the injured area and enhances healing.

There are considerable costs when investing in hydrotherapy both initially in the equipment and room, but also in on-going staffing and maintenance of the pool or treadmill, so careful calculations and cost analysis need to be performed to ensure it is the right piece of equipment for your practice. It is also essential that staff using the hydrotherapy are part of the Canine Hydrotherapy Association and properly trained in understanding the principles and practicalities of using it effectively, but when done properly the results are clear to see:

“Sophie is a 13-year-old Labrador suffering from long term ear infections as well as severe OA. She was unable to go for walks, the yard/ garden was all she could manage. She was unable to have medication due to allergies, sensitivity and internal issues. Owners had tried everything for the ears and the OA and were about to consider PTS as the final option…… Sophie had about 12 laser sessions on her ears alone which has cleared the infection up and we have so far in 8 months not seen it back. The combined laser and hydrotherapy ensures she is strong enough to go for 3 x 30-minute walks and is now mobile, energetic and playful, the owners believe that she will outlive them due to how well she has done through the treatment”, Michael Leonard at NE Hydro centre.

“Often owners will contact us enquiring about when they can start their hydrotherapy post-operative, in the past we have had to have a longer period before we could start any treatment. Now that we have the laser we start treatment as soon as possible after their surgery with the use of the laser therapy to assist in wound healing and pain management. We have found this to be a very successful

way of speeding up their rehabilitation as well as getting the dogs or cats to feel comfortable with the new environment and being handled by our staff.

When rehabilitating numerous orthopaedic clients, who have received surgical intervention, such as TPLO surgery. We have found that incorporating the laser into the hydrotherapy programme we have noticed a significant difference in the time taken for the effected limb to return to normal function”, Charlotte at Woozelbears Hydrotherapy.

REGENERATIVE MEDICINE FOR 21st CENTURY VETS

Contrary to general practitioner belief any small animal or equine vet can utilise regenerative medicine within their practice to improve clinical outcomes post-surgery or as part of a multi-modal management of osteoarthritis. This is not some holy enclave of referral specialists.

In principle whether Stem cells, BMAC (Bone Marrow Aspirate Concentrate) or Platelet Rich Plasma growth factors (PRP) they have similarities:

1) Autologous – only cells derived from the animal can be re-injected back in a concentrated form. It is illegal in the UK to inject allogenic cells into the same species.

2) Super-concentrate - Require some method of collecting the cells and increasing the concentration prior to re-injection back into the same animal

3) Regeneration - Utilise cellular trophins or growth factors to stimulate tissue regeneration, accelerated healing or anti-inflammation

4) Clinically Proven – all three categories have clinical publications showing efficacy across a wide range of species and musculoskeletal or wound injuries, but variation between marketed and sold products varies dramatically.

This is a hugely exciting forefront of medical science that will push the boundaries of what we are capable of doing for our patients. BUT, this is a poorly regulated market, in 2016 the VMD closed down several laboratories that were selling “Stem Cells” to veterinary practice due to poor clinical standards. In addition, most UK marketed products have data extrapolated from clinical trials based within research institutes and universities, but lack actual published data on their own equipment for concentrating these “regenerative cells”, or double-blinded studies on the efficacy from the end concentrate versus saline. Also, as we are dealing with biological products, variation between individual’s cell concentrates and growth factors, and huge differences in the level of tissue damage, will result in variation amongst the end clinical results. Owners and veterinary surgeons must be realistic in what can be achieved in end-stage joint damage, best results are gained from early proactive use of regenerative medicine in the disease process.

There are also considerable variations in cost for the veterinary clinic and the end consumer, so caution and through investigation of the specific marketed product chosen is necessary to ensure ease of use, sterility, efficacy and cost effectiveness are all achieved to ensure all parties are satisfied with the end result.

“We have used the V-PET on hocks, shoulders, cruciates, elbows all good effect with or without surgery. What initially convinced me of merits of the product was treating my own dog with early onstage arthritis that was on NSAIDs for two years. One V-PET injection and my dog is healthy, more active and completely off all NSAIDs” Mark Mincher-Lockett, E.C. Straiton and partners.

“Investing in equipment to enhance our offering. We invested in two class IV lasers (one for each branch). These devices have become an essential component of our multi-modal, osteoarthritic management (MMOAM) combination. Also of importance is regenerative medicine. We generally use intra-articular injections of platelet rich plasma (PRP). Minimal investment is needed for this procedure where filtration methods are used.

Patient benefits We have observed enormous patient benefits with MMOAM. The majority of pets respond well to this combination of measures. The use of class IV laser especially, has allowed large reductions in NSAID use. Similarly, PRP has exceeded our expectations in efficacy. Pets after MMOAM are generally less painful, more active and leaner.

Client benefits Clients tend to report that they have get their puppy back once MMOAM takes effect. The increased comfort and ability and desire to exercise enhances the human-pet bond and results in very high client satisfaction.

Team benefits The principles of MMOAM are easy to learn yet the rewards for the team in job satisfaction are enormous. Veterinary nurses become empowered by being the professionals who administer the laser.

Business benefits Our MMOAM offering is one of the most profitable services in our practice.

Russell Chandler, Alphavets, Newport.

ACUPUNCTURE IN VETERINARY MEDICINE

The use of acupuncture within veterinary medicine is becoming a more common in the management of acute inflammation and chronic pain, and has been well documented in veterinary publications. Acupuncture origins date back over 3000 years to China, and uses 350 energy force points, “Qi” within the body’s meridian lines to treat disease. Today the majority of UK veterinary surgeons use a variant called Western Acupuncture to manage their patients.

Acupuncture dry needling inhibits nociceptive transmission, improves blood flow and inhibits inflammation. Dry needling stimulates nerve fibres resulting in changes in motor neuron tone, vasodilation, inhibition of spinal pathways and release of central nervous system’ opioids. Training is required to accurately understand the pathophysiology and placement of the needles with the Association of British Veterinary Acupuncturists running regular training courses. Increasingly laser light acupuncture is being used to stimulate the “Qi” points providing photon energy equivalent to the needle point. This can be especially useful in animals, especially cats, that do not tolerate placing multiple needles in them. Electroacupuncture uses electricity passed through acupuncture needles to created enhanced, long-lasting analgesia. Surgical studies have been performed on cattle which allowed analgesia solely to be provided via electroacupuncture technique.

“On my return to practice it was with some trepidation that I took the plunge and offered acupuncture to a client whose old dog was in significant pain from severe DJD and was reacting badly to the standard therapies. I have been pleasantly surprised by the results. The procedure is well tolerated by the patient and owner, there are no short or long-term side effects, and I am able to offer another alternative which is vigorously embraced and beneficial”, Phil Burns, Lakeview vet centre.

SUMMARY

In this rapidly evolving medical environment, demands on veterinary practices and their staff will continue to present challenges and opportunities: increasingly knowledgeable customers, older and

more complex conditions to manage in pets, a demand for more natural alternatives. Thus, multi-modal complementary options are good clinical, manpower and economic choice to incorporate within the modern veterinary practice. Beware though, lack of regulation does require the practice to investigate both the clinical validity and economics of what best suits their specific practice and client base. Thorough due diligence will be rewarded in providing higher levels of accelerated healing and pain management, client satisfaction, staff empowerment and new profitable income streams by adopting complementary medicines into your practice.